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Showing results for "patient safety".

421. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - Improving patient safety is a key initiative across the system, as safety is the basis upon which all … This HRO attribute is epitomized by the Joint Commission’s patient safety standards, which allow any … Staff see PEERs as an opportunity to share issues not related to patient safety. … PEERs reports also have driven patient safety in the obstetrics department. … used across Trinity Health to assess patient safety for the system.

422. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
     January 01, 2007 - The overall goal of the cooperative agreement was the improvement of patient safety by implementation … and use of a statewide voluntary patient safety reporting system. … safety events in hospitals; e.g., AEs per 1,000 patient-days. … , lifting patients, walking patients. … Promoting patient safety by preventing medical error. JAMA 1998; 280:1444-1447. 11.

423. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - A tale of two stories: Contrasting views of patient safety. … Geneva, Switzerland: World Alliance for Patient Safety; 2005. 6. … House of Commons Committee of Public Accounts, A safer place for patients: Learning to improve patient … Patient safety: Achieving a new standard for care. … Beyond Babel: Prospects for a universal patient safety taxonomy.

424. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
     April 03, 2008 - This initiative was recently awarded the 2007 National Patient Safety Foundation’s “Stand Up for Patient … Plans to recognize patient safety champions with safety award certificates and “Most Valuable Player … Keeping patients safe: Transforming the work environment of nurses. … Patient safety: Achieving a new standard of care. … Sensemaking of patient safety risks and hazards.

425. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
     July 17, 2008 - MEDMARX is a potential data source for patient safety organizations (PSO). … Safety and Quality Improvement Act of 2005 calls for the creation of patient safety organizations ( … Safety (PIPS) grants from AHRQ to fund the project, Implementing a Program of Patient Safety in Small … Structure and Process as Determinants of Medication Safety Analyses from large patient safety databases … The patient safety and quality improvement act of 2005.

426. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - There was no patient contact in this process. … Resar26 has noted that the goal of patient safety should be a focus on harm reduction rather than on … Patient safety in the ambulatory setting: A clinician- based approach. … Ambulatory patient safety. What we know and need to know. … In: Advances in Patient safety: From research to implementation.

427. Development of a Comprehensive Medical Error Ontology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
     June 16, 2008 - Safety Event Taxonomy7 (PSET) • Patient information • The event • Patient outcome • Product … Such querying techniques would help in identifying potential targets for which patient safety interventions … The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near … Organization and representation of patient safety data: Current status and issues around generalizability … Doing what counts for patient safety: Federal actions to reduce medical errors and their impact.

428. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
     January 01, 2007 - Introduction Efforts to increase patient safety within hospital settings are numerous and have resulted … In 1996, in conjunction with an institutional movement to QI, patient safety efforts refocused on systems … When developing patient safety reporting systems, providers should take care to learn from successful … Key to any patient safety endeavor is the creation of a reporting system that takes into account limited … Medical teamwork and patient safety: The evidence-based relation.

429. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
     February 23, 2008 - However, the VA’s National Center for Patient Safety identified some cases in which clinicians attempted … The survey was sent by e-mail to patient safety managers at all 163 VA hospitals in September 2002. … Department of Veterans Affairs identified a significant issue through their patient safety program: … Author Affiliations VHA National Center for Patient Safety, Ann Arbor, MI. … Stalhandske, MPP, MHSA, VHA National Center for Patient Safety, 24 Frank Lloyd Wright Drive, Lobby M

430. The Rural Physician Peer Review Model©: A Virtual Solution (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Williams_115.pdf
     June 19, 2008 - Approach of Quality Improvement/Patient Safety RCHI leaders searched for ways to implement the hallmarks … of the perspective of patient safety and quality improvement. … They assumed that quality and patient safety in health care could be improved by introducing organizational … Patient safety issues, Joint Commission requirements, and other regulatory mandates are discussed as … care, and it promotes systems thinking and quality and patient safety improvements for a significant

431. Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hueckel_27.pdf
     April 01, 2008 - Because of growing interest in these systems, experts in the field of patient safety and critical-care … need with triage, direct patient care, or escalation of patient monitoring.2 Patient safety, evaluations … safety. … The PRRT and Rover Teams contributed to an environment of patient safety. C. … safety.

432. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - Although the mandate was designed to improve patient safety, the long-term success of mandatory reporting … If handled correctly, 1 medical adverse event reporting has the potential to improve patient safety … The overarching theme propelling this mandatory change is patient safety. … Patient safety toolbox for states. Portland, ME: National Academy State Health Policy. … Patient safety and medical adverse event: A roadmap for state action. Portland, ME.

433. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
     March 03, 2008 - Standard safety interventions for all patients admitted to the hospital Environmental safety 1. … Patient safety 1. … safety, patient safety, and daily routines (Table 2). … for patient safety. … The ABCD model for patient safety.

434. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
     March 23, 2008 - Sections were developed and ordered based on a review of patient safety literature. … The incorporation of patient safety into board certification examinations. … Promoting patient safety and preventing medical error in emergency departments. … id=5882 Appendix: EM Trainee Patient Safety Questionnaire PATIENT SAFETY QUESTIONNAIRE DEFINITION … Safety Questionnaire PATIENT SAFETY QUESTIONNAIRE Not at all important (1) Not important (2) Somewhat

435. Common Cause Analysis: Focus on Institutional Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
     January 20, 2008 - an RCA team is chartered through the Patient Safety Officer. … safety by focusing on one topic at a time, including patient falls, medication errors, or missing patients … a prioritized quality and patient safety goal. … VA National Center for Patient Safety; 2007. … Using aggregate root cause analysis to improve patient safety.

436. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - In its examination of medical errors and patient safety, the Institute of Medicine (IOM)4, 5, 6 concluded … Patient safety: Achieving a new standard for care. … TeamSTEPPS: Strategies and tools to enhance performance and patient safety: Instructors guide. … Medical teamwork and patient safety: The evidence-based relations. … Video capture of clinical care to enhance patient safety.

437. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
     March 19, 2008 - the efficiency and safety of this process. … safety, a multidisciplinary team was formed to improve pediatric oncology patients’ outcomes. … order sessions with problematic chemotherapy orders would improve patient safety. … is proactively focused on safety promotion vs. … Risk reduction for adverse drug events through sequential implementation of patient safety initiatives

438. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - In an effort to promote patient safety at our institution, we implemented a monthly interdisciplinary … In an effort to promote patient safety at our institution, we implemented a monthly hospital-wide morbidity … Children’s Hospital at Vanderbilt to improving patient care and safety. … care and safety. … safety.

439. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
     March 27, 2008 - Comput Support Coop Work 2001; 10: 317- 346. 8. 2008 National patient safety goals. … Healthcare systems, ergonomics and patient safety. … Focus Patient Safety 2004; 7: 1-3. 25. Kowalsky J, Nemeth CP, Brandwijk M, et al. … Closing the communication loop: Using readback/hearback to support patient safety. … Improving patient safety by repeating (readback) telephone reports of critical information.

440. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - a primary goal in patient safety. … safety also are the ones with the largest potential for patient hazards. … This is an important step toward the goal of reducing hazards and improving patient safety. … Patient safety: Improving safety with information technology. … In: Advances in Patient Safety: New Directions and Alternative Approaches.